Issued and entered June 4, 2003 by Linda A. Watters, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On May 6, 2003, XXXXXXXXXXXXXX filed a request for external review with the Commissioner of Financial and Insurance Services under the Patient’s Right to Independent Review Act (PRIRA), MCL 550.1901, et. seq. After a review of the material submitted, the Commissioner accepted the request. The issue involved is medical in nature. The Commissioner therefore assigned the case to an independent review organization (IRO) on May 13, 2003. On May 27, 2003, the IRO provided its recommendation to the Commissioner.

II
FACTUAL BACKGROUND

Petitioner is a XXXXXXXXXXX woman with a history of endometriosis and pelvic pain. Her treating physician ordered blood tests to determine if the current treatment should be continued. Blue Cross and Blue Shield of Michigan (BCBSM) denied payment for the laboratory work done on XXXXXXXXXXXXXXXX, indicating the testing was for screening purposes and therefore not payable. Petitioner appealed the decision.

On April 9, 2003, BCBSM held a Managerial-Level Conference as part of the Petitioner’s grievance process. BCBSM then issued a final adverse determination upholding the denial stating the laboratory tests were not medically necessary for the Petitioner’s condition.

II
ISSUE

Did BCBSM properly deny payment for laboratory work on XXXXXXXXXXXXXXXX, as medically unnecessary?

IV
ANALYSIS

Petitioner’s Argument

Petitioner is XXXXXXXXXXXX and is being treated for endometriosis and pelvic pain by an OB-GYN. She has been on birth control pills to suppress the endometriosis. Petitioner has a family history of diabetes, hypercholesterolemia and hypertension. The doctor ordered blood studies to evaluate her cholesterol and glucose levels. A TSH (Thyroid Stimulating Hormone) and a Comprehensive Metabolic Panel were ordered as part of the yearly examination.

In a letter dated XXXXXXXXXXXXXX the Petitioner’s doctor stated the patient has had a good response to treatment. To determine possible complications with continued use of birth control pills, the patient’s family history required lipid and glucose testing. The blood studies were needed to check the patient’s cholesterol level and to screen for diabetes.

BCBSM’s Argument

The Petitioner has health coverage under BCBSM’s Comprehensive Hospital Care Group Benefit Certificate (Certificate). The request for coverage of laboratory tests was reviewed at a Managerial-Level Conference April 9, 2003. The amount in dispute is $244.34 for the following laboratory tests:

Under the terms of pages 8 and 9 of the Certificate, services must be medically necessary to be covered. To be medically necessary a service must be for the treatment, diagnosis or symptoms of an injury, condition or disease. The service must be appropriate for the symptoms and consistent with the diagnosis. The medical consultant concluded the tests were ordered for screening purposes. Therefore, the tests are not covered and the Petitioner is responsible for paying the $244.34.

IRO Recommendation

The IRO medical reviewer is a practicing physician who is board-certified in obstetrics and gynecology. The IRO is familiar with the medical management of patients with the Petitioner’s condition. According to the reviewer, oral contraceptive use can be contraindicated in patients with hyperlipidemia and/or diabetes. The Petitioner is over 35. The reviewer determined the lipid screen and glucose testing were medically necessary for the diagnosis and treatment of this patient’s condition. Testing of lipids is particularly important for a patient with a family history of hypercholesterolemia. Testing for diabetes with a glucose test is important because the results may impact treatment with oral contraceptive pills. Thyroid testing and a metabolic screen are not medically necessary for the treatment of patients with endometriosis who are being treated with oral contraceptives.

Commissioner’s Review

The Commissioner agrees with the IRO’s medical expert regarding laboratory tests for the Petitioner’s condition. Testing cholesterol level and screening for diabetes for a patient over XX years of age, with a family history of elevated cholesterol, hypertension and diabetes to determine whether the use of birth control pills should be continued for the treatment of endometriosis are medically necessary. Thyroid testing and a comprehensive metabolic screen are not medically necessary for the treatment of patients with endometriosis with oral contraceptives. The lipid and glucose testing on XXXXXXXXXXXXXXXX, were medically necessary and are therefore covered under the Certificate. The thyroid screening and metabolic screen were not medically necessary for diagnosis and treatment of her condition.

V
ORDER

The Commissioner reverses in part BCBSM’s final adverse determination. BCBSM is required to pay for the lipid screening and glucose testing which are medically necessary to treat the Petitioner’s condition. The thyroid testing and the metabolic screen performed as part of a yearly check-up were not medically necessary. BCBSM is not required to pay for those tests.

This is a final order of an administrative agency. Under MCL 550.1915, any person aggrieved by this order may seek judicial review no later than sixty days from the date of this order in the circuit court for the county where the covered person resides or the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.